Supervisor Service

Application for Employment

XOtech LLC is an equal opportunity employer and does not discriminate against otherwise qualified applicants on the basis of race, color, creed, religion, ancestry, age, sex, marital status, national origin, disability or handicap, or veteran status.

PERSONAL INFORMATION

Name Date Last First Middle

Other Names By Which You Have Been Known Address Street City State Zip

Previous Address, If Current Address Is Less than 5 Years: Street City State Zip

Social Security Number Home Phone Cell Phone Business Phone E-mail address POSITION DESIRED

Position Date Available Salary Desired Referred by

EDUCATION

Indicate Last Level Completed: High School College/University Graduate School Include any additional educational, vocational, professional or other information you feel may be helpful to us in considering your application.

Name of School Location Course/Degree Dates Attended Name

MILITARY SERVICE

Branch of Service Dates of Service Duties/Special Training Do you have a security clearance? Yes No

If yes, please indicate what level EMPLOYMENT HISTORY

Start with your present or most recent employer. Please include any job related military service assignments and volunteer activities. If you were self employed, give firm name. Name of Current/Last Employer City State May we contact your Employer? Yes No

Telephone Job Title Full-time Part-time Start Date End Date

Starting Salary Ending Salary

Name and Title of Supervisor Title and Duties Reason for leaving Name of Previous Employer City State May we contact your Employer? Yes No

Telephone Job Title Full-time Part-time Start Date End Date

Starting Salary Ending Salary

Name and Title of Supervisor Title and Duties Reason for leaving Name

Name of Previous Employer City State May we contact your Employer? Yes No

Telephone Job Title Full-time Part-time Start Date End Date

Starting Salary Ending Salary

Name and Title of Supervisor Title and Duties Reason for leaving Name of Previous Employer City State May we contact your Employer? Yes No

Telephone Job Title Full-time Part-time Start Date End Date

Starting Salary Ending Salary

Name and Title of Supervisor Title and Duties Reason for leaving PERSONNEL DATA

Have you been convicted of a crime (other than a traffic violation) or been imprisoned within the past seven years? A conviction will not necessarily bar you from employment. Yes No

If yes, give date, place, offense and outcome:

Name

REFERENCES

List three professional references that are familiar with the quality of your work, have worked with you directly and have known you for at least two years. NAME

ADDRESS

PHONE NO.

JOB

TITLE

YEARS

KNOWN

AUTHORIZATION

I certify that the facts in this application are true and complete to the best of my knowledge and understand that if employed, falsified statements on this application shall be grounds for dismissal. If I am employed by XOtech, I understand that just as I am free to resign at any time, XOtech reserves the right to terminate my employment at any time, with or without cause and with or without prior notice. I understand that no representative of XOtech has the authority to make any assurances to the contrary. I authorize investigation of my previous work experience and other information provided to XOtech in connection with efforts to obtain employment and during my continued employment. I authorize the references and previous employers listed to give you any and all information concerning my previous salary history, employment history and any pertinent information they may have, and release all parties from all liability for any damage that may result from furnishing same to you. I understand that any offer of employment is contingent upon the results of investigations into my previous work experience and other information provided.

I understand that if not selected for employment, this application will remain on file for a period of six months from the date shown below.

XOtech employment offers are contingent on passing a drug and substance abuse screening test and a background investigation. Employment candidates who refuse to take such a test(s) will not be considered further for employment. Failure to pass the test(s) may result in withdrawal of employment offers.

XOtech is an equal opportunity employer. No question on this application is used for the purpose of limiting or excluding any applicant’s consideration for employment on a basis prohibited by local, state or federal law.

Signature of Applicant Date

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